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Summary of the impact

ASSIST (A Stop Smoking in School Trial) is reducing smoking rates among
teenagers by 22%. `DECIPHer' Impact Ltd was set up to rollout the ASSIST
programme which has been adopted widely in England and Wales with 26
licences being commissioned. The company has achieved £240K annual
turnover. As a result, an estimated 1674 young people have not taken up
smoking. The Lancet estimates that if ASSIST were implemented
across the UK, 40,000 teenagers a year would not start smoking.

ASSIST has been commended by the English and Welsh Governments and
recommended in National Institute for Health and Care Excellence (NICE)
guidelines.

Underpinning research

Smoking kills nearly six million people a year and is forecast to kill
one billion people in the 21st century. Tobacco users who die
prematurely leave their families without income, increase the cost of
healthcare, and impede economic development. In the UK, smoking accounts
for nearly 20% of deaths and costs the NHS around £2.7 billion every year.
Children who start smoking before the age of 16 are twice as likely to
continue as adults (compared to those who start later). They are also more
likely to have respiratory illnesses, use alcohol and drugs, and be absent
from school compared to those who do not smoke.

Preventing young people from starting to smoke is a key element of
tobacco-control strategies. ASSIST is based on an American model where
opinion leaders in the gay community train others to promote better sexual
health choices. ASSIST adapted this model and trained and supported
influential Year 8 school students (aged 12-13) to support their friends
and classmates [1]. These `peer supporters' have informal conversations
with other Year 8 students about the risks of smoking and the benefits of
being smoke-free.

ASSIST was a joint initiative of the Universities of Bristol and Cardiff.
In the major part of the research the intervention was further developed
and evaluated by a randomised controlled trial (RCT) funded by the Medical
Research Council [2]. Rona Campbell from the University of Bristol led
this research jointly with Laurence Moore of Cardiff University. The RCT
followed young people for two years and found ASSIST was effective in
reducing smoking uptake by 22% over this period [3]. The trial results
were published in The Lancet and estimated that if implemented
throughout the UK, the programme would prevent 40,000 young people taking
up smoking each year. The research also evaluated the delivery process to
help understand what made the programme successful. It found that ASSIST
was implemented with a high degree of fidelity and was acceptable to
schools and teachers, and to the young people who received it [4,5].
Further analysis also indicated that the ASSIST intervention was cost
effective [6].

More detailed follow-on research on the peer supporters found that those
who were asked to work informally, rather than under the supervision of
teaching staff, took the responsibility seriously and were effective at
passing on messages about not smoking to their peers [5]. This is a
research finding of considerable significance that can be applied to other
health areas.

The RCT fieldwork was carried out equally by Bristol and Cardiff
universities. The data analysis for the RCT was conducted in Bristol and
Bristol took the lead in publishing research from the RCT: eight of the
nine journal papers produced have a Bristol-based first author (Campbell,
Audrey, Starkey and Hollingworth) and in six of the nine papers Rona
Campbell is the senior (last-named) author. Jo Holliday was seconded to
Bristol from Cardiff for 9 months to work on the dissemination of ASSIST.

References to the research

[1] Audrey S, Cordall K, Moore L, Cohen D, Campbell R on behalf of ASSIST
(A Stop Smoking In Schools Trial). The development and implementation of a
peer-led intervention to prevent smoking among secondary school students
using their established social networks. Health Education Journal
2004. 63(3) 266-284. http://dx.doi.org/10.1177/001789690406300307

Details of the impact

Impact on Policy

The research associated with the development and evaluation of ASSIST has
had a substantial impact on policy.

In February 2010, the UK government published `A Smokefree Future',
its White Paper on tobacco control. It outlines future policy and
focuses on the use of evidence-based policies in three areas, the first
of which is `To stop the inflow of young people recruited as smokers'
[a]. The review of evidence into smoking and young people which informed
this White Paper identified ASSIST as a `potentially important
intervention' [b].

ASSIST has been cited as an example of good practice in another
Government White Paper, Healthy Lives, Brighter Futures: The
Strategy for Children and Young People's Health [c].

It was also flagged as an example of an effective preventative
strategy aimed at young people in the NHS Stop Smoking Services:
Service and Monitoring Guidance [d].

Guidance published by NICE, `School-based Interventions to Prevent
Smoking',[e] which was informed by four separate reviews [f, g],
has a specific recommendation on peer-led initiatives. It states that
those commissioning health care should `consider offering
evidence-based, peer-led interventions aimed at preventing the uptake of
smoking such as the ASSIST (A Stop Smoking in School Trial) programme'
and refers the reader to the main trial results published in The
Lancet.

The Tobacco Action Plan for Wales, published in February 2012,
has, as one of four strategic action areas, `reducing the uptake of
tobacco use, especially amongst children and young people.' It restates
the Welsh Government's continuing commitment to providing the ASSIST
programme to 40 to 50 schools per year, focussing on areas of
deprivation.[h]

Implementation of ASSIST

The research intervention was faithfully translated into a practical
model that can be implemented by national, regional and local bodies with
health and education responsibilities. The major vehicle for dissemination
has been DECIPHer (the Centre for the Development and Evaluation of
Complex Interventions for Public Health Improvement), the UKCRC (UK
Clinical Research Collaboration) Public Health Research Centre of
Excellence jointly established by the universities of Bristol, Cardiff and
Swansea.

In order to ensure effective support for the implementation of ASSIST and
to maintain its integrity, the universities of Bristol and Cardiff created
DECIPHer Impact Ltd, a `not for profit' company, limited by guarantee
which aims to maximise the translation and impact of evidence-based public
health improvement research and expertise. Its first product is ASSIST,
which is trade-marked as the DECIPHer-ASSIST smoking prevention programme.
Licences are sold by the company and purchasers receive DECIPHer-ASSIST
materials, training, support and ongoing quality assurance. This ensures
that DECIPHer-ASSIST is implemented in a high quality way and maximises
the likelihood that the effects found in the RCT are reproduced in real
world implementation.

There has been substantial demand for DECIPHer-ASSIST from local
healthcare purchasers [i]. To date 25 health bodies in England and the
Channel Islands have been issued with licences costing up to £34K each. A
more substantial licence has also been issued covering the whole of Wales,
where ASSIST is being implemented at a rate of 40-50 schools per annum.
Company turnover in the year ending July 2013 was £240K [i]. In its recent
tobacco control policy the Scottish government committed to pilot ASSIST
and discussions are ongoing with state and educational institutions in
France and Germany about implementing ASSIST.[i] To date over 350 UK
schools have been involved in the programme and over 150 staff from former
primary care trusts and local authorities have been trained to deliver the
programme.

Impact on teenagers

The use of ASSIST is growing every year. In the academic year 2012/2013
over 25,000 Year 8 students (via more than 4,500 peer supporters)
were involved in DECIPHer-ASSIST. By summer 2013 more than 60,000 Year 8
students and over 11,000 peer supporters were involved in DECIPHer-ASSIST,
resulting in 1674 fewer teenagers taking up smoking.[i]

Recognition of the impact on health

In 2011 DECIPHer-IMPACT was the overall winner of the Bristol Health
Partners Health Innovation Award [j] which recognises outstanding health
innovation achievements. In 2013 DECIPHer- IMPACT won the Innovation in
Healthcare Award as part of Cardiff University's Innovation and Impact
Awards 2013[j].

Sources to corroborate the impact

[a] Department of Health (2010) A smokefree future: A comprehensive
tobacco control strategy for England. White Paper (p 31).This
substantiates that the research associated with ASSIST has had an impact
on policy.

[b] Amos A and Hastings G, Angus K, Bostock Y, Fidler J. (2009). A review
of young people and smoking in England. Public Health Research Consortium.
(p97) This is a review cited in [a] which further substantiates the impact
on policy.

[c] Department of Health (2009) Healthy lives, brighter futures: The
strategy for children and young people's health (p 59). Substantiates the
impact on policy.

[f] Bauld L, Brandling J, Templeton J (2009) Facilitators and barriers to
the delivery of school- based interventions to prevent the uptake of
smoking among children: A systematic review of qualitative research
Available at:http://www.nice.org.uk/nicemedia/live/12827/47627/47627.pdf
. Substantiates the impact on policy.